Form 5498-Esa - Coverdell Esa Contribution Information - 2012 Page 2
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CORRECTED
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TRUSTEE’S or ISSUER'S name, street address, city, state, and ZIP code
1 Coverdell ESA contributions
OMB No. 1545-1815
Coverdell ESA
2012
Contribution
$
Information
2 Rollover contributions
5498-ESA
$
Form
Copy A
TRUSTEE’S/ISSUER’S federal identification no. BENEFICIARY'S social security number
For
Internal Revenue
BENEFICIARY'S name
Service Center
File with Form 1096.
Street address (including apt. no.)
For Privacy Act and
Paperwork Reduction
Act Notice, see the
City, state, and ZIP code
2012 General
Instructions for
Certain Information
Account number (see instructions)
Returns.
5498-ESA
Form
Cat. No. 34011J
Department of the Treasury - Internal Revenue Service
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page
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